Science and not blowing the lid on the cancer and sunscreen “myth”

Is sun screen really effective in counteracting damage from overexposure to the sun? Dermatologists agree that sunscreen is a necessary preventative measure for sun damage to the skin and even skin cancer.

Every now and again an article will appear in print or on the Internet discussing the dangers of sunscreen or claiming that the sun and skin cancer link has been debunked. I recently re-read an article online that stated, “Scientists blew the lid on the cancer and the sunscreen myth”.  Reading it made me grin, as these articles always do, because….no we didn’t.

These articles are mostly click-bait, sensationalized journalism that distorts science and fact to support an eye-catching headline. I respect the innovation and manipulation, as well as the need to simply increase the size of the audience. But the amount of ridiculousness in this article is hilarious, so I couldn’t help but respond.

The foundation of this article and others like it is a Swedish study published in 2014 and it’s an interesting study.

Lets review the facts of this study.

29,518 Swedish women from ages 25 to 64 answered a survey with a variety of questions principally aimed at how frequently they sunbathed. For 20 years the women were followed and national databases were checked to see who died and who developed melanoma.

The survey study found that all-cause mortality (death for any reason) was inversely related to sun exposure habits.  Meaning that over the 20-year period, twice as many women from the lowest sun exposure group died as compared to the highest sun exposure group.

The study has no idea as to what the participants died of and does not comment on significant baseline health habits of these groups, though their data showed the non-sunbathers group to have a higher rate of non-exercisers and obesity. The study also does not measure vitamin-D at any point, nor does the study have anything to do with sunscreen. In fact, the words sunscreen or sunblock are not found in the study at all. Not even as commentary.

That’s it. Those are the facts. Notwithstanding, the association is truly fascinating and has value on its own. But any statement that expounds upon the aforementioned finding is conjecture, and while conjecture is an important part of discovery it should be taken, as they say, with a grain of salt.

The authors of the study surmise that perhaps low vitamin D is to blame for the noted trend of increased death among the non-sunbather group. It is certainly a possibility. Vitamin D is an essential vitamin and sun exposure is a significant source of vitamin D production and important in Vitamin D levels. In order to come to this conclusion the authors of the study make a few assumptions.

First, that the women’s sun exposure habits did not change over a 20-year period. Second, that the consequences of an unhealthy lifestyle, obesity and lack of exercise, that appeared to be more prevalent in the non-sunbather group, did not affect their results. Third, that Vitamin D levels were chronically low in the women who self-reported to have low sun exposure, and that the other group’s levels were not.

Now, the issues with the first two assumptions are relatively clear. But the problem with the third assumption may not be as clear, so lets talk vitamin D.

Dermatologists and other medical practitioners agree that vitamin D is an essential part of a healthy lifestyle, but how much is too much?

I don’t think any physician would challenge the importance of Vitamin D. It is essential for a number of physiologic processes and organ systems. It appears to be protective in several conditions including more aggressive forms of melanoma, and a growing number of studies support the idea that low levels of vitamin D are linked to an increased risk of heart disease. This vitamin is something you need and want in your body.

But remember that vitamin D is not obtained by sunlight alone. And there is a limit on the amount our skin can produce.  As such the vitamin is also, in many instances,  an essential part of our diet.

Only a modest amount of sun exposure is required to make sufficient amounts of the vitamin, several minutes at midday in the summer months are sufficient for many Caucasians. And after reaching the production limit, further exposure may actually destroy the vitamin.

Furthermore, UV exposure is unlikely to produce enough vitamin D in people with very dark skin. People with darker skin types produce less of the vitamin in response to the same amount of sunlight. Also, the elderly have a reduced ability to synthesize vitamin D from sunlight, and during the winter, sunlight is insufficient to produce vitamin D in people living above 42 north latitude, which includes Boston and northern California.  Sweden, where the study was conducted, is well north of this. Which means that regardless of how frequently a study participant sunbathes, vitamin D may need to come from the diet as well for a significant part of the year.

The authors of the online article are more shameless in their assumptions. They assert, “Researchers concluded that the conventional dogma, which advises avoiding the sun at all costs and slathering on sunscreen to minimize sun exposure, is doing more harm than actual good.” This is a lie on two accounts, the definition of dermatologic dogma and about the researcher’s thoughts on sunscreen.

The current dermatologic dogma is focused on sun protection, not sun avoidance. No reasonable dermatologist would advocate for complete sun avoidance unless you are a vampire, have a photosensitive disorder, or have undergone a recent procedure that warrants temporary but strict sun protection for an optimal outcome. And sunscreen, as mentioned above, is not part of the referenced study.

The article also paraphrases a well-known dermatologist who effectively said, “There’s no proof that increased exposure to the sun increases the risk of melanoma.” True, but this is only part of the story.

Does the sun cause skin cancer. Yes. Unequivocally yes. Ultraviolet (UV) radiation from the sun causes mutations in the DNA of skin cells that are very closely linked to certain types of skin cancer. What often gets overlooked is the fact there are different types of skin cancer. Squamous cell carcinoma and basal cell carcinoma are highly associated with the amount of sun exposure and sun damage over a person’s lifetime. Melanoma is a different beast and while there is no evidence to suggest a causal relationship between simple sun exposure and melanoma, there does seem to be an association of some kind.

The article then goes on to reference a second Swedish study published in 2000 titled “Sunscreen use and malignant melanoma”. They misrepresent the authors by saying that the study “concluded that higher rates of melanoma occurred in those who used sunscreen versus those who did not.”

While this is technically true it is seriously misleading. The authors of the study actually concluded, “sunscreen use, by permitting more time sunbathing, is associated with melanoma occurrence.” This statement/theory on the researchers part was further supported by the fact that the association between more frequent sunscreen use and melanoma was stronger in men, and people using sunscreens with SPF of 10 or lower. Meaning that the people using more sunscreen where hypothesized as getting more sun exposure and using the sunscreen ineffectively.

Regardless of the facts and your interpretation thereof, skin cancer is not the only untoward effect of excessive sun exposure. Sun damage also results in wrinkles, loss of collagen, uneven pigmentation, and premature aging.  And many people find these reasons for sun protection to be more compelling.

Overall, there are clear benefits from prudent exposure to the healing rays of the sun, physically and emotionally. But protection and moderation is, at this time, what the medical community painstakingly tries to suggest.
The best approach to sun exposure, as recommended by cosmetic dermatologists, is moderation and spf protection.

If you’re simply thinking I’m biased because I’m a dermatologist, you’re probably right.  I suppose that in the end, more UV radiation is ultimately good for business.  If we really do need to get more sun, and subsequently increase the incidence of sun related skin conditions, in order to better our chances of living longer, then I’ve got plenty of job security to look forward to.

Exciting News for Aging Hands

Dr. Smart treated this patient's sagging skin, a sign of aging often shown first in the thinner skin of the hands and neck, with simple cosmetic dermatology procedures in his Salt Lake City dermatology clinic.

Do your hands give away your age?

Frequently we focus on the face when discussing cosmetic improvement, but there are other telling locations that can be treated.   One the areas that most give away our age is the hands. As we age, our hands lose firmness and plumpness and begin to look fragile and bony. The veins become more prominent, the skin starts to look thin and often becomes speckled with brown spots from sun exposure.

Combating the aging hand takes more than hand cream, though that simple step does make a difference. But cosmetic filler is often the answer.

This month the US Food and Drug Administration (FDA) approved the injectable dermal filler Radiesse (Merz North America, Inc) for hand augmentation to correct volume loss in the dorsum, or back, of the hands. This is great news!!   Radiesse is a fantastic way to turn back the clock and bring a youthful soft appearance to the back of the hands.

Radiesse injections immediately revitalize and replenish the volume of the back of the hands. And provide a supple and youthful appearance instantly. Placed beneath the skin, Radiesse raises the skin level so that tendons, joints and veins lose their prominence.

Also, because Radiesse provides support and a scaffolding for the deep skin tissue, the body’s own collagen is stimulated and begins to interweave with the filler and helps keep the skin feeling soft, natural, and smooth.

The Results typically last 1 – 2 years with immediate improvement.

In the studies used to gain FDA approval the most common side effects were extremely mild and include injection site reactions such as swelling, redness, pain, and bruising, which were usually mild to moderate, short in duration (lasting about 1 week), and required no treatment. No severe adverse events were reported.Signs of aging showing in hands before simple cosmetic dermatology procedures to reduce signs of aging performed by Dr. Smart at The University of Utah's Salt Lake City clinic

Tight Skin! ThermiTight

Over time the effects of gravity and aging slowly take their toll on us all. And for several reasons certain areas on the face and body unfortunately start to droop and sag, and the skin loses its youthful rebound and tension.

In short, life happens. Skin gets loose. And people want to keep it tight.


Skin tightening is a popular request in a dermatologist’s office, and the world of aesthetic medicine and technology continues to try to meet the increasing demand with new approaches and treatments. A relatively new treatment modality of an already proven technology is ThermiTight.

ThermiTight is an application of the ThermiAesthetics system that uses radiofrequency (RF) technology to safely rejuvenate the skin. It is also one of the most effective “non-surgical” skin-tightening treatments I’ve seen. We’ve had great results.

There are many different devices in this non-surgical skin-tightening realm. Some work well, some less so, but none that I have yet seen work better or as reliably as the TermiTight. This is not to say that I don’t like, use, and recommend other methods. I do. But I’ve recently been quite impressed with the results of this treatment method.

ThermiTight’s RF energy induces the reduction of wrinkles, tightens skin and helps contour the body by heating underneath the skin, the hypodermis, and the layer of adipose tissue found there. It causes the release of liquid fat from fat cells and induces fat cells to shrink in the treatment area while also stimulating new collagen formation and contraction.

This procedure may be administered on several areas:

  • Lower face and neck
  • Arms
  • Legs
  • Stomach
  • Breasts
  • Hips
  • Back

It is also frequently combined with other procedures such as liposuction or laser resurfacing which reduces fine lines and wrinkles on the surface of the skin.

The fact that the RF energy is applied directly to the hypodermal layer is what makes it stand out. A fact that likely accounts for increased efficacy, but does make it minimally invasive. Unlike ultrasound or laser techniques, in which energy is placed on the surface of the skin and directed internally, RF energy stimulates the skin from within. The use an internal probe to apply energy below the surface of the skin directly targets the collagen.

Screen Shot 2015-05-09 at 6.46.46 PM

The treatment begins by administering local anesthetic to the treatment site. Tumescent anesthesia is used, which means that a diluted lidocaine mixure is used to flood the target area.   A thin, specialized probe is then inserted through a very small incision (2-3mm) to reach the subdermis. The probe is then slowly moved back and forth to evenly heat the treatment area. The continuous temperature monitor on the probe is set to the desired level required to tighten the skin, while an infrared camera is used to monitor the skin surface temperature and ensure the heat energy is maintained at an effective and safe level. The treatment lasts for less than 60 minutes, with results that develop gradually over 3-6 months. After the procedure, the patients are free to resume normal activities the next day. There is very little recovery time, with temporary bruising or swelling being the most common side effects.

For patients with skin that is drooping naturally from aging or significant weight loss ThermiTight might just be exactly what they are looking for.

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Stretch Marks

Stretch marks are noticeably lighter and less visible after only five laser treatments from Dr. Smart at The University of Utah's Department of Dermatology
Before and after 5 treatments of the Fraxel laser

The Stretch Mark

Why do stretch marks form? Well…. from stretching right? Probably, but the precise cause of stretch marks, also known as striae, is not quite understood. While many believe that mechanical stretching of the connective tissue causes rupture and their subsequent appearance, there is more to it than that. And even normal growth associated with high levels of steroid hormone may be the cause.

Whatever the cause, many of us have a stretch mark or two. They are a very common cosmetic concern and more than twice as likely in women, compared to men.  But regardless of gender, they can be frustrating to us all.

Keep in mind, we divide striae into two groups, striae rubra (SR) and striae alba (SA). SR are a little bit pink, red, or purple, relatively new, and may be raised. SA are typically older, light colored and slightly atrophic or thinned. These categories are important because they are treated a little differently.

How to treat your stretch marks:

Treatment of stretch marks includes a variety of topical and injectable medications and laser therapy and resurfacing techniques.

Tretinoin and similar topical creams have shown to clinically improve the appearance of SR in clinical trials. Daily application over the period of 3-4 months may help exfoliate and tighten the mark. Other topical therapies that show benefit are glycolic acid and Trichloroacetic acid (10-35%) These are typically applied at monthly intervals.

Another proven therapy is microdermabrasion. By carefully and gently abrading the superficial layer of skin, deeper new collagen regeneration is stimulated and the texture of the striae can be smoothened and strengthened.

There are also a variety of laser and light devices that have been studied to treat these pesky stretch marks. By using a combination of different lasers, such as the V-beam and Fraxel lasers, Good to great results can be achieved in both newer red stretch marks and older white colored ones.

Personally, I like the results I get with laser resurfacing. Fractionated laser resurfacing will help tighten the skin and improve the appearance of stretch marks both new and old.

A few technical details:

 The PDL 585-595nm lasers have perhaps the most evidence and are able to achieve good results when treating the early SR. Their effect is less impressive on mature SA.   Though caution should be used on much darker skin types with this laser. And in darker skin types one might consider a different wavelength such as a 1064nm ND: YAG. This provides increased safety when treating dark skin types, while still provided collagen regeneration and targeting vasculature.

The treatment of SA is more difficult and less predictable.  Studies show conflicting results with various fractionated laser modalities. but both ablative and non-ablative fractionated lasers have shown improvement. And both should be considered options in patients with mature striae.

Another consideration in SA may be the 308nm excimer laser. Multiple studies have documented improvment and repigmentation in white or light colored areas with the excimer.

The Cosmeceutical

What skin creams will be best for keeping away signs of wrinkles and aging? Cosmetic dermatologists warn that not all skin creams are created equal and to investigate and research fully the claims of your skin care routine before committing time and money to a product.Cosmeceutical is the term currently used among dermatologists to refer to the area between cosmetics and pharmaceuticals. The FDA defines cosmetics as articles intended to be topically applied for cleansing, beautifying, promoting attractiveness without affecting structure or function. Whereas pharmaceuticals are defined as compounds designed to be used as medicinal drugs. As you can imagine the requirements and FDA regulations place on the manufacturing and marketing of new drugs is dramatically different than the regulations placed on makeup.

The cosmetic industry is a vibrant and growing market, and this is a bit of an understatement.   Revenue from the cosmetic and skin care industry is over $ 50 billion annually in the US alone, and nearly a third of that is defined as facial skin care. The US is not unique in its cosmetic inclinations. In fact, global industry sales reach close to $200 billion annually with the largest consumer being Asia.   In short, the skin care market continues to grow on an impressive international scale.

As this occurs, the sophistication of raw materials, compounds, and formulations used in this arena increases. In conjunction, a greater appreciation of the top layer of the skin, called the stratum corneum, has been achieved through the use and basic study of these non-invasive bioengineered creams.

Research clearly demonstrates that non-prescription topical agents can dramatically influence the stratum corneum, and that these agents can indeed penetrate the stratum corneum and influence skin function. Thus cosmetics and skin care products are assuming an increasingly important role in clinical dermatology.

One of the foundational dermatologic texts defines a cosmeceutical as “a scientifically designed, useful product intended for external application to the human body that has desirable aesthetic effects and meets rigid chemical, physical and medical standards.”  But it also readily recognizes that “there is no regulatory description that acknowledges the current scientific sophistication of these formulations”. Which means that cosmecuetical products currently do not need to rigorously demonstrate that they are what they say they are, or do what they say they’ll do. And consequently, in many physicians’ minds walk a fine line between evidenced based medicine and snake oil.

What this means for you? You need to get your product from a trusted source and beware of online fraudulence. Also take the products claims with a grain of salt and a healthy degree of skepticism. You can think of the industry oversight as being similar to that of vitamins and supplements. A company’s claims about the product do not have to be rigorously substantiated through scientific study. They only have to prove safety, not efficacy, and not even content sometimes. You may want to seek real, sound, evidenced based medical advice. And even more importantly, beware of online fraudulence.Cosmetic dermatologist advice on skin care products

Counterfeiting and theft are real issues with medical grade skin care products. A quick Google search will show you high-end cosmetic skin care products for only a fraction of the cost. Products like SkinCeuticals, Biopelle, EltaMD, SkinMedica, TNS, and Neocutis found online are perhaps the most suspect, as these skin care lines are principally sold in medical clinics and spa settings, any online distribution should be seriously scrutinized. But the fraudulence is not limited to these brands. Even impure Botox is cheaply purchased online.

Shipments are stolen and sold to consumers, products are counterfeited with different creams and sold in identical packaging, or expired products can be repackaged or sold that won’t give you the full benefit you expect.

Keeping that in mind, there are plenty of great companies making cosmeceuticals out there that are high in quality with good scientific evidence to back their efficacy in helping to rejuvenate and maintain skin tone and texture.

Do you have rosacea? Botox!

Botox treatments make a noticeable difference in the redness of the skin in a patient suffering from rosacea

Yet another use for Botox:

Rosacea is an extremely common and frequently frustrating skin condition. For all those that suffer from the redness and flushing that accompanies rosacea, also called erythematotelangiectatic rosacea, a novel and impressively effective therapy is again in the news, Botox.

In a recent study published in Dermatologic Surgery. Intradermal injections of Botox were found to be safe and effective in treating the facial redness of rosacea.

In the study multiple injections were performed “intradermally” and the amount used ranged from 15-45 total units. Unquestionably, patients noticed decreased flushing, erythema (redness), and inflammation within one week. The results persisted 3-6 months.

Even though the injections of Botox were placed into the cheeks, none of the study patients experienced any weakness or relaxing of the smile or cheek muscles. This may be secondary to the amount and, more likely, the location in which the product was placed. Botox when used to treat wrinkles is not injected intra-dermally, but deeper, either sub-dermally or intramuscularly.

Botox blocks the release of the neurotransmitter acetylcholine, which plays a role in local vascular control. It should be noted however that neurovascular regulation is much more complex than simple acetylcholine release. Thus, there have also been case reports of this treatment approach being ineffective in some patients. This illustrates the complexity of the condition.

For those of you that suffer from rosacea, you know that there are very few treatment options to truly target the redness that accompanies rosacea. A newer topical medication called Mirvaso, targets the redness by constricting the superficial blood vessel in the skin and can do a great job in a temporary fashion, but I have seen mixed results in practice and have my own concerns about the product. And then of course there are lasers.

Laser therapy remains the gold standard for the treatment of erythematotelangiectatic rosacea. They just work. Unfortunately since they are not covered by insurance in the vast majority of cases, these options may not be talked about enough with patients suffering from the disease.

Botox for rosacea represents a new and interesting application of a surprisingly complex medication. And it is always nice to have options in medicine.  If you suffer from rosacea, consider laser or Botox. You will be pleased.


Taking care of your skin with topical retinoids

retin AThere are a few simple recommendations and practices that should be included in any basic skin care regimen.  Appropriate
moisturization and exfoliation, protection from harmful UV radiation, and avoiding the significant damage caused by harsh toxins such as those found in cigarette smoke are a few such recommendations.  And certainly, in patients with
lighter skin tone, the use of topical retinoids (a class of chemical compounds long used in cosmetic creams and in the treatment of various skin disorders) could be included in this list.

A study published in the Journal of Drugs in Dermatology explores the efficacy and tolerability of two topical treatments for
photoaging, photodamage, and fine lines/wrinkles on the face.  The study compares two commonly used vitamin A derivatives, retinol and tretinoin.

Retinol is an over the counter compound found in many cosmetic creams marketed to treat wrinkles and to rejuvenate the skin.  Tretinoin is a similar more potent compound available by prescription, and is most commonly found in topical acne therapies.  Tretinoin has been used to effectively treat acne for many years, but has also long been used as a prescription strength anti-wrinkle cream.

The study enlisted patients with photodamage (blotchy skin coloring from sun damage) to use retinol on one side of the face and tretinoin on the other for a period of 12 weeks.  And the results from the study were undeniable.  The regular daily use of topical retinoids produced noticeable improvement in photodamage.  Meaning It helped to even tone and texture by lightening brown spots, smoothening rough patches, and fading fine lines.

retinol before and after
Before and after 12 weeks of daily use retinol 5% cream. Notice the subtle improvement in fine lines and dark spots.

Confirmation is always nice, but the fact that topical retinoids help with fine lines is not news.  What I found more interesting however, is that there seemed to be little to no difference in improvement between the retinol and the tretinoin treated sides.  Meaning that both sides of the face improved to similar degrees. The results of this study support the notion that over the counter cosmetic products containing retinol might be similarly effective as the prescription tretinoin formulations. Another reason why this may be good news is that tretinoin creams tend to be more irritating to the skin, causing occasional dryness, flaking, redness, and burning sensation.

It should be noted that there are multiple shortcomings and potential confounding variables in the study, including an obvious conflict of interest as the study was designed, executed, and paid for by a cosmetic skin care company that produces over the counter retinol creams.  As an aside, this particular company makes products that I really like and have found to work well in my own practice.  But I think the take home message for me from this study is unhindered by these questionable detractors. Skin care is important and has an appreciable effect on skin health and appearance weather you use over the counter products
or prescription strength medication.  You only get one face. Take care of it.

Botox for depression

Can botox help patients suffering from depression? Dermatologists and scientific research are finding this is a viable treatment for patients suffering from depression. Dr. Smart of The University of Utah advises patients that botox could be the missing treatment in their struggle with depression.

Positive effects on mood have been seen in patients who’ve had Botox
treatment for the glabella and frown lines (the area above the nose
and between the eyebrows).  And a randomized, double-blinded, placebo controlled trial recently published in the Journal of Clinical Psychiatry adds further evidence to support the use of botox as an adjunctive therapy to treat depression.

In this study a total of 30 patients with high levels of chronic and
treatment-resistant depression were enrolled in the study. Patients
were randomly assigned to receive a single injection of Botox or a
single injection of saline (placebo). Six weeks after a single
treatment, the Botox group had an average 47.1% reduction in
depression symptoms vs. 9.2% in the placebo group.

Why would this work?  Our emotions are expressed by facial muscles,
which in turn send feedback signals to the brain to reinforce those
emotions. Treating facial muscles with botulinum toxin to prevent the
facial muscles from expressing a frown or brooding scowl seems to
interrupt this cycle.

Neither this concept nor the evidence presented here are particularly new, but I never fail to find the link between the physical and the emotional fascinating. Or maybe people are just happy when their wrinkles get better.

Great Lips

lip enhancements are a simple and common procedure at cosmetic physician's offices. Lip enhancement procedures are regularly performed by David Ross Smart, MD at The University of Utah's Department of Dermatology

Great lips are great.

Having full, plump lips is often considered a sign of good health and youth. And symmetric, well-shaped, proportionate lips are generally regarded as an alluring, cross-cultural sign of beauty.  For these reasons injectable lip enhancements are common and popular procedures in the cosmetic physician’s office.

As we age, the lips can slowly lose their fullness and shape.  The distance between the bottom of the nose and the upper lip sags and slightly lengthens, giving the upper lip a longer and thinner appearance.  And adding or restoring volume and shape to the lips is an easy non-invasive way to quickly enhance overall beauty in many patients.

Lip enhancement is simple, quick, and carries immediate reward with relatively low risk.  A good lip enhancement is generally subtle, accentuating the natural shape of the lip, correcting any asymmetry, and sometimes simply adding volume.

When done well, the effect is impressive and patients are very pleased. However, they have not always been done well.   Poorly filled or over-filled lips are readily noticeable, and the picture of someone with those shapeless, overfilled, sausage lips has, over the last couple of decades, become the pop culture poster child of bad cosmetic surgery.  But the majority of good lip enhancements go almost unnoticed because they are natural and subtle.

A good candidate for lip enhancement:

A good candidate is someone who wants to accentuate the shape, improve proportion, or correct some of the volume loss that has happened over time, then they might be a good candidate.

As always with elective cosmetic interventions, motivation and expectations about outcomes are important considerations when deciding if someone is a good candidate.  Is the patient considering lip augmentation to make someone else happy or to try to fit an ideal image? If so, the patient should think twice about it.  Enhanced lips may make your lips plumper and fuller, but you will still be you when you walk out of the doctor’s office.

lips before and after a visit to the cosmetic dermatologist

Before and after photos of a standard cosmetic dermatology procedure by Dr. Smart
before and after 1cc of Juvederm

Lip augmentation is a simple procedure that can be done easily at a cosmetic dermatologist office

before and after images of a lip augmentation performed by David Ross Smart, MD at The University of Utah Department of Dermatology

It is important to remember that not everyone needs their lips filled.  I certainly don’t advocate that.

What to expect during the procedure:

Before the injections, a topical or local numbing agent may be applied to ease discomfort. Sometimes injections can be given before the treatment to completely numb the lips.  After carefully marking the areas to be injected, very fine needles are used to inject the substance into your lips.  Following injection, ice may be given to ease discomfort and control swelling.  Lipstick or other lip products are best avoided immediately after the procedure.  You should be able to notice a difference immediately.

A little more in depth:

Attaining the perfect lip proportions is possible with just a few visits at a cosmetic physician's office

Aesthetic lips:

  • An appropriate upper to lower lip size ratio
  • A distinct cupids bow
  • Fullness and a concave sloping of the upper lip in profile
  • A defined and thick vermilion border
  • A prominence or presence of philtral columns
  • Upturned oral commissures

Aging lips:

  • Flattening of philtral columns
  • Lengthening of the cutaneous upper lip
  • Thinning of the lip and volume loss
  • Convex sloping in profile
  • Downturned oral commissures
  • Loss of the natural vermiliocutaneous pout

The proportions: 

Perfect Lip proportion?
Note that while 1/3 is written, the upper lip is clearly not 1/2 of the size of the lower.

Achieving the perfect lip proportions is possible with simple cosmetic dermatology procedures offered by Dr. Smart at The University of Utah Department of Dermatology

Different sources will state slightly different things. The most commonly quoted is the golden ratio, 1.0:1.6, as demonstrated in the above diagram. However, it has been my experience that these ratios convey perception and  not reality.  Great lips do not quite fit any of these ratios. In fact, even the diagrams used to illustrate the proposed ratios are noticeably erroneous.   Regardless, the point is that the upper lip is proportionally small than the lower.  If you are only injecting the upper lip then you are setting yourself up to fail.  The tubercles of the lower lip must be addressed and evaluated to maintain the appropriate proportion.

What to focus on when evaluating and correcting:

1. Philtral columns
2. Cupids bow
3. Lateral edges of the cupids bow and the white roll of the upper lip
4. Tubercles of the lower lip
5. upturn of the corners of the mouth

Lip enhancement is not a one-size-fits-all procedure, and an aesthetic eye is applied to evaluate the needs of each situation.

Perfect lips for women models

Fraxel Dual, a laser for the brown spots

solar lentigo

Freckles, dark spots, age spots, liver spots, or sun spots. Whatever you want to call them, these brown patches, medically termed lentigo, are typically found on the face and hands and can make us look older than we feel.  Here are some pictures of what I mean:

lentigo blue eye

lentigosolarLentigo_handsolarLentigo_man cheek

There are many ways to get rid of or lighten these pesky brown spots.  While many lasers, chemical peels, and a variety of creams are used to treat these lesions, and treat them effectively, I’ve been very impressed with results from the fraxel dual laser.

The Fraxel is a very popular cosmetic treatment, and it is also used  is used to treat scarring, fine lines and wrinkles as well as lightening the brown spots and smoothening blotchy pigmentation that comes with sun damage.

The Fraxel is considered a facial resurfacing laser that works by creating a checkerboard pattern of thermal or heat energy in the skin. This energy being delivered with laser precision causes specifically placed heat injury to the skin which results in a type of peeling or exfoliation. This in turn causes skin tightening and new collagen formation.  Here are some pictures of results from the fraxel laser when used specifically to treat “lentigo”.

Fraxel lenitgo
After 2 treatments
Before, 2 days after, and 1 week after 1 treatment
Screen Shot 2014-09-23 at 11.09.02 AM
After 2 treatments

The Fraxel is not as aggressive as some other facial resurfacing methods which makes this a comparatively very safe option with little to no downtime depending on each individuals response and how comfortable you are going into work with a little redness and maybe some peeling.  Some mild swelling for a couple of days is not unusual either. And sometimes a few treaments are needed to get the desired effect, especially when using the Fraxel to treat scars and wrinkles.


A little more detail:

The Fraxel laser was initially launched as a 1550nm erbium fractionated non-ablative laser. A later model called the Fraxel dual was produced and has the classic 1550mn setting as well as a 1927nm thulium laser setting.

Terms to know from the previous paragraph:

Ablative vs. non-ablative

Ablative lasers are more aggressive as they vaporize the tissue, Non-ablative lasers cause damage to the desired target cells through heat energy, but do not vaporize the tissue.

Fractionate vs. non-fractionated:

Fractionated lasers deliver energy in a checkerboard pattern, which can be beneficial in certain treatments as it leaves zones of untreated skin that make the subsequent healing process more rapid.

.fractionated pattern

The 1550nm setting has been used for years as an effective resurfacing laser for wrinkles and to tighten the skin. The 1927nm setting was added to better target the brown discoloration.

When used to treat wrinkles the results achieved from one treatment of the Fraxel are not nearly as impressive as from one treatment of an ablative laser. The upside however, is that the Fraxel has much less social downtime, and fewer side effects. A series of Fraxel treatments (typically 3 to 6 treatments) at 2- to 4-week intervals is recommended for the best clinical outcome when trying to treat skin laxity and wrinkles. Fewer treatments are necessary when you’re goal is to treat brown spots. Repeated Fraxel treatments can achieve a similar result for acne scars when compared to traditional ablative laser skin resurfacing.   However, the improvement seen after a series of Fraxel treatments for very deep wrinkles around the mouth and eyes often falls short of the impressive results that can be achieved with ablative laser skin resurfacing.